Your benign prostatic hyperplasia medication: When to consider a change

If you are like many of the 14 million men in the United States who have been diagnosed with benign prostatic hyperplasia (BPH), you’ve probably been taking the same medication, at the same dose, for years. If so, consider the experiences of two patients, both of whom were taking some type of medication for BPH. Their names have been changed, but all other details are accurate (see “Jack Muriel” and “Henry Banks” below).

Jack Muriel

At 64, Jack was taking tamsulosin (Flomax) for moderate BPH but otherwise was in good health. Recently retired, he looked forward to a weekly round of golf with friends at a local country club. One evening, while driving home to meet his wife for dinner, Jack suddenly became lightheaded. He felt as if he were about to faint. He managed to pull the car over to the side of the road and call for help. While dialing, he thought, “Maybe I shouldn’t have taken the Viagra and Flomax at the same time.”

Henry Banks

At 77, Henry was generally in good health, but had been taking terazosin (Hytrin) for his BPH for years. At one point, after Henry experienced a bout of unexplained abdominal pain, his internist ordered an abdominal CT scan to determine the problem. As instructed by the radiology department, Henry drank large quantities of water before the procedure. The CT scan itself went fine, but afterward, Henry found he could not urinate, even though his bladder was full. Instead of returning home after the CT scan, Henry wound up in the emergency room, where he had to have a catheter inserted.

Jack and Henry experienced unexpected consequences while taking a BPH medication. Fortunately none of these consequences had long-lasting health effects — and they could be avoided in the future by making some adjustments. In Jack’s case, the problem was mixing a BPH medication with one for erectile dysfunction. Although many men use both medications without difficulty, some may need to take precautions. Henry might have been able to avoid a visit to the emergency room if, before getting a computed tomography (CT) scan, he’d told the radiologist that he had been taking a medication for severe BPH.

Certainly some type of adverse event, such as these men experienced, might make you wonder if it’s time to adjust the dose of your medication or perhaps even change medications. But there are other considerations as well. Every man is different. In this article, you’ll learn about the types of issues many men with BPH have confronted, and what situations might indicate it’s time to consider a change in medication.

Issues to consider

The two classes of drugs currently approved to treat BPH — alpha-1 blockers and 5–alpha-reductase inhibitors — work in entirely different ways, and therefore raise different types of issues. So it’s important to understand these differences as you evaluate which medications might be right for you.

Simply put, alpha-1 blockers deal with the “going” problem by relaxing certain muscles in the prostate and urinary tract, while 5–alpha-reductase inhibitors deal with the “growing” problem by reducing the size of the prostate (see Figure 1).

Figure 1. How BPH medications work

How BPH medications work

A. As the prostate gland enlarges, it constricts the urethra, which carries urine out of the body, and may expand up into the bladder itself. This not only impedes urinary tract functioning, but also reduces the volume of urine the bladder can hold.

How BPH medications work

B. Alpha-1 blockers attach to certain receptors in the muscle walls — much as a key fits into a lock. By blocking alpha-1 receptors, alpha-1 blockers prevent insertion of the chemical keys that signal a muscle to contract. The muscles relax and urine flows more freely.

How BPH medications work

C. The 5–alpha-reductase inhibitors have a different mechanism of action: They neutralize 5–alpha reductase, the enzyme that initiates conversion of testosterone into dihydrotestosterone, or DHT, the form of the hormone that is usable in the prostate. By blocking the action of the chief male hormone responsible for growth of the prostate, these drugs eventually cause the prostate to shrink.

The alpha-1 blockers are classed into two groups. The selective agents, alfuzosin (Uroxatral), silodosin (Rapaflo), and tamsulosin (Flomax, generic), work primarily on the tissues of the urinary tract. The nonselective agents, doxazosin (Cardura, generic) and terazosin (Hytrin, generic), affect both the urinary tract and other tissues elsewhere in the body. The 5–alpha-reductase inhibitors, which include dutasteride (Avodart) and finasteride (Proscar, generic), act directly on the prostate.

Other medications are in development (see “Anticholinergic drugs” and “PDE-5 inhibitors,” below), but are not yet available. So for now, you’ll have to weigh the relative risks and benefits of alpha-1 blockers and 5–alpha-reductase inhibitors.

Anticholinergic drugs

These medications are used to quiet overactive bladder muscles, which can lead to urinary incontinence. Investigators have discovered in the past few years that more than half of men with BPH also suffer from overactive bladder, and that this may further exacerbate urinary difficulties. Researchers are now investigating whether taking anticholinergic drugs can ease BPH symptoms.

When it comes to recommending one drug or another, urologists often use some general guidelines: Alpha-1 blockers are better at relieving urinary symptoms such as difficult or frequent urination, and are best for men with smaller prostate glands. But 5–alpha-reductase inhibitors may be in order if you have a large prostate gland or have not obtained sufficient relief from alpha-1 blockers. And they have a stronger track record for reducing the chance that you’ll need surgery or will experience complications such as acute urinary retention. Sometimes the medications are prescribed in combination.

Time to change?

Any of the following suggests that you should re-evaluate your BPH medication:

  • Your BPH symptoms worsen, even though you are taking your current medication.
  • You notice side effects that weren’t affecting you before.
  • You start taking a drug for some other medical condition — or add drugs to an existing regimen (for example, you add another medication to help control your high blood pressure).
  • You start taking a drug for erectile dysfunction.

Speed of relief

The alpha-1 blockers work quickly, taking effect in days to weeks. But the nonselective agents may require some patience, as doses have to be increased slowly at first, to avoid lowering your blood pressure too much. Doctors usually start with 1 milligram (mg) at bedtime, then gradually increase it as needed to a maximum of 10 mg of terazosin or 8 mg of doxazosin. This process, known as titration, may be frustrating for you as well because you will need to wait to find the correct therapeutic dose.

Dosing is simpler for the selective alpha-1 blockers. For tamsulosin, you take 0.4 mg or 0.8 mg half an hour after dinner. Alfuzosin is a time-release formulation, so a single 10-mg tablet is taken once a day immediately after a meal.

With the 5–alpha-reductase inhibitors, it takes longer to feel the results. These drugs shrink the prostate by reducing levels of the male hormone dihydrotestosterone (DHT), which promotes prostate growth. Levels of DHT fall precipitously after several weeks of taking a 5–alpha-reductase inhibitor, but it may take at least three to six months, and perhaps even longer, before you notice any improvement in urine flow.

Combination therapy

When it comes to BPH, are two drugs better than one? The Medical Therapy of Prostatic Symptoms (MTOPS) study indicated that the answer may be yes — at least for some men. In the study, 3,047 men with BPH were randomly assigned to take doxazosin (Cardura), finasteride (Proscar), a combination of the two, or a placebo. After roughly four and a half years of observation, the combination reduced the risk of BPH progression (symptoms getting worse) by 66% when compared with placebo, significantly more than either drug alone. Compared with placebo, doxazosin reduced BPH progression by 39%, and finasteride reduced it by 34%.

A 2006 reanalysis of the MTOPS data according to prostate gland size found that combination therapy provided the most benefit to men whose prostate glands were 25 grams or greater in size (see “MTOPS study and reanalysis,” below).

MTOPS study and reanalysis

McConnell JD, Roehrborn CG, Bautista OM, et al. The Long-Term Effect of Doxazosin, Finasteride, and Combination Therapy on the Clinical Progression of Benign Prostatic Hyperplasia. New England Journal of Medicine 2003;349:2387–98. PMID: 14681504.

Marberger M. The MTOPS Study: New Findings, New Insights, and Clinical Implications for the Management of BPH. European Urology Supplements 2006;5:628–33.

Some men with large prostates try combination therapy to get fast relief for their symptoms from the alpha-1 blockers. In six months or so, when the 5–alpha-reductase inhibitors begin taking effect, these men may stop taking the alpha-1 blockers.

However, you should consider two additional pieces of information when contemplating whether to start combination therapy: cost and side effects. First, taking two pills is more expensive. If you have to pay for medications on your own, or if your insurance company requires some type of co-pay, you may want to figure cost into the equation. Second, although the MTOPS study found that side effects were similar whether men took one drug or the combination, many experts feel differently, based on the patients they see.

High blood pressure

The nonselective alpha-1 blockers block alpha receptors in the heart and blood vessels as well as in the prostate, lowering blood pressure in the process. While these agents are usually not the first choice for blood pressure control, they may be a good choice for men who have both BPH and high blood pressure. If you want to limit the number of different medications you are taking, ask your doctor whether using a nonselective alpha-1 blocker might enable you to control both your BPH and your blood pressure — and then monitor both your urinary symptoms and your blood pressure to make sure the medicine is really working for you.

If you are already on another medication to control your blood pressure, or are taking an erectile dysfunction drug, then taking a nonselective alpha-1 blocker carries the risk that you will experience lightheadedness, faintness, dizziness, or postural hypotension (a drop in blood pressure that occurs when you sit or stand quickly, as when getting up from a chair or out of bed). Although a panel of Harvard experts thought the risk of hypotension was minimal, it’s still worth knowing about. Sudden episodes of low blood pressure can be dangerous if you already have some type of vascular disease, because it increases your risk of suffering a heart attack or stroke.

Similarly, because of these side effects, the nonselective alpha-1 blockers may not be the best choice for you if your blood pressure is already on the low side.

The selective alpha-1 blockers, alfuzosin, silodosin, and tamsulosin, have less of an impact on blood pressure, so they may be good alternatives in these situations. (Men taking silodosin may notice a drop in blood pressure upon standing.) Or consider taking a 5–alpha-reductase inhibitor.


The nonselective alpha-1 blockers (doxazosin and terazosin) are available now in generic as well as brand name formulations, and so may save you some money (see Table 1). Of course this may also depend on what type of drug coverage is included in your health insurance plan, and how much of a co-pay you need to contribute.

Table 1. Cost of BPH drugs compared

The costs below are based on average wholesale prices to pharmacists and the lowest dosage; costs to patients may be more.

Drug class Generic name (brand name) Estimated cost per month for generic, if available Estimated cost per month for brand name medication
Nonselective alpha-1 blockers doxazosin (Cardura), 1-mg tablets $17.99 $51.67
terazosin (Hytrin), 10-mg tablets $13.99 n/a
Selective alpha-1 blockers alfuzosin (Uroxatral), 10-mg tablets n/a $129.16
silodosin (Rapaflo), 8-mg capsules n/a $124.99
tamsulosin (Flomax), 0.4-mg tablets $120.99 $142.18
5–alpha-reductase inhibitors dutasteride (Avodart), 0.5-mg capsules n/a $123.57
finasteride (Proscar), 5-mg tablets $70.08 $112.99
Prices given are those charged by the online retailer as of Oct. 1, 2010 for a one-month supply (30 capsules or tablets). They do not take any discounts or insurance coverage into consideration. Drug prices may vary, and your pharmacy may charge more.

Sexual side effects

Because they affect levels of the male hormone testosterone, the 5–alpha-reductase inhibitors may cause a variety of sexual side effects. In the original clinical trials, 3.7% of men taking these drugs (and 4%–6% by some other estimates) developed erectile dysfunction. Another 3.3% of men experienced a decline in libido, while 2.8% had problems ejaculating during an orgasm.

In addition, one of the selective alpha-1 blockers, tamsulosin, causes ejaculation problems in some men who take it. The other alpha-1 blockers may cause less of this problem.

Erectile dysfunction is treatable with three medications, and it is generally safe to take these drugs when you are taking your BPH medication, whether it is an alpha-1 blocker or a 5–alpha-reductase inhibitor; however, we offer some important cautionary advice.

If you develop problems with ejaculation during sex, the solution depends on what medication you are taking. If you are taking a 5–alpha-reductase inhibitor, the only way to resolve the ejaculation difficulties is to stop taking the BPH medication, so you may need to decide on another medication (or surgery) to deal with your urinary difficulties. However, if you are taking tamsulosin, you may be able to alleviate ejaculation problems by taking the drug every other day (see “Alternate days,” below).

Alternate days

Investigators asked 140 men with BPH to take 0.4 mg of tamsulosin (Flomax) daily for three months. If the men responded to tamsulosin, they were randomized to one of three groups. One group continued taking the medication daily, the second took the same dose every other day, and the third stopped taking the drug. Men taking tamsulosin every other day did just as well as those taking it daily, and experienced fewer side effects such as ejaculation problems.

Source: Yanardag H, Goktas S, Kibar Y, et al. Intermittent Tamsulosin Therapy in Men with Lower Urinary Tract Symptoms. Journal of Urology 2005;173:155–7. PMID: 15592062.

Gynecomastia (breast enlargement), another possible side effect of the 5–alpha-reductase inhibitors, is rare but is distressing when it occurs. Stopping the medication may reverse the problem. But not always: Some men have had to undergo breast reduction surgery — or learn to live with the changes.

Medications for erectile dysfunction

Three medications have been approved for the treatment of erectile dysfunction: sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). These medications are all PDE-5 inhibitors, which generate nitric oxide, a chemical that enables arteries to widen. The increased blood flow to the penis helps to produce an erection. The problem is that arteries elsewhere in the body widen as well, causing a slight drop in blood pressure.

If you are considering an erectile dysfunction medication, you don’t have to worry if you are also on one of the 5–alpha-reductase inhibitors for your BPH: The drugs can be taken together without adverse effects. However, if you are currently using, or considering, an alpha-1 blocker, you may want to take some precautions when adding one of the PDE-5 inhibitors.

Here’s why: Because the PDE-5 inhibitors cause a system-wide drop in blood pressure, theoretically they can exacerbate the blood pressure–lowering action of the nonselective alpha-1 blockers doxazosin and terazosin. This seems especially to be a problem when taking sildenafil (Viagra) and vardenafil (Levitra); tadalafil (Cialis) is a longer-acting PDE-5 inhibitor, and the risks are less clear.

As a result, some doctors recommend that if you are using a nonselective alpha-1 blocker for BPH, you should avoid taking an erectile dysfunction medication altogether. However, our panel of Harvard experts think the concerns are overblown. If you don’t want to stop using a nonselective alpha-1 blocker for your BPH, you can make sure you take the PDE-5 inhibitor at different times of the day (take one medication after lunch, say, and the other in the evening) to avoid problems.

Or you can lower the dose of your alpha-1 blocker or PDE-5 inhibitor. That is what Jack Muriel eventually decided to do. He’d taken his BPH medication, Flomax, along with Viagra before heading home to have dinner with his wife. The combination created the dizziness that caused him nearly to run off the road. His doctor suggested he try lowering his dose of Viagra in the future, to 25 mg (from the 100–200 mg he’d been taking), because that would lessen the chance of dizziness if he took it along with the Flomax. Or, if that dose was not sufficient, he could try 50 mg of Viagra. But to prevent problems, he needed to make sure that he took it at least four hours before (or after) he took the Flomax.

PDE-5 inhibitors

Could these medications, already approved to treat erectile dysfunction, also alleviate BPH symptoms? The answer may be yes, according to early studies of sildenafil (Viagra) and tadalafil (Cialis) — although the dosing is different than for erectile dysfunction. The medications may help by relaxing smooth muscle within the prostate, thereby improving the flow of urine. However, more research is needed.

Prostate cancer

The Prostate Cancer Prevention Trial showed that taking one of the 5–alpha-reductase inhibitors, finasteride, reduced the risk of developing prostate cancer by 24.8% — an astounding amount, and a result that would normally change the practice of medicine.

But here’s the bad news — and why you need to consider your choice of finasteride carefully: Men in the study who took finasteride were more likely to develop high-grade cancer (the type more likely to spread and become life-threatening) than those taking a placebo. In the PCPT study, high-grade prostate cancers developed in 37% of the men taking finasteride who developed tumors (6.4% of all the men taking finasteride), compared with 22% of the men taking placebo who developed tumors (5.1% of all men taking placebo).

So what’s going on? It’s not clear. The PCPT study has generated heated discussion, and one leading theory is that because finasteride shrank the prostate gland, doctors had a smaller target to sample, and were therefore more likely to find cancer. It is unclear whether the findings also apply to dutasteride, but because the drug is in the same class, most researchers think it does. For now, check with your own urologist for advice about what you should do.

Pay attention to PSA levels. If you decide to take a 5–alpha-reductase inhibitor, whether it’s only for your BPH symptoms or because you also want to reduce your overall risk of prostate cancer, you’ll need to understand how these medications will affect your PSA levels. In general, 5–alpha-reductase inhibitors tend to reduce PSA levels by about 50%, although the actual reduction varies from man to man. It is important to obtain a baseline PSA value before beginning treatment with one of these medications, and then have another after 6–12 months, to see how much the PSA has gone down after treatment. This follow-up PSA then becomes your new baseline.

You’ll need to figure this new baseline into your calculations as you monitor your PSA in the future. So, for example, if you start taking a 5–alpha-reductase inhibitor, and your PSA falls from 3 to 1.5, that’s to be expected. But if it should double over the course of a year, say from 1.5 back to 3, talk with your doctor about whether to have a prostate biopsy. Even though a value of 3 is considered “normal” in men not taking a 5–alpha-reductase inhibitor, a PSA value that doubles within a year of beginning one of these medications could indicate that cancer is present.

Acute urinary retention

Henry Banks developed acute urinary retention after drinking large quantities of water for a CT scan. This is a medical emergency, because if someone is unable to urinate and excrete urine, over time pressure that builds up in the bladder can adversely affect the kidneys, possibly leading to kidney failure — which is life-threatening.

For most men, of course, the most tangible worry about acute urinary retention is that they may have to have a catheter inserted to relieve pressure on their bladder — which is simply uncomfortable, bothersome, and potentially embarrassing (the catheter can sometimes leak, causing accidents). Sometimes a man can be weaned from the catheter and return to taking a BPH medication, but not always. A man who has developed acute urinary retention may need to consider surgical options to alleviate his symptoms.

BPH progression

Although BPH symptoms often remain stable, one study found that progression was likely in men with the following clinical profile:

  • Age 62 years or older
  • Prostate size of 31 grams or greater
  • PSA of 1.6 ng/ml or greater
  • Urine flow less than 10.6 ml per second
  • Post-void residual of 39 ml or greater

Source: Crawford ED, Wilson SS, McConnell JD, et al. Baseline Factors as Predictors of Clinical Progression of Benign Prostatic Hyperplasia in Men Treated with Placebo. Journal of Urology 2006;175:1422–7. PMID: 16516013

To reduce your risk of developing acute urinary retention, you have two options. The first is to take some common-sense precautions, no matter what BPH medication you are on. Watch your intake of fluids, especially if you will be unable to urinate for a while (such as when you’re at a sporting event or on a long airplane trip). If your doctor recommends a medical test that requires you to drink fluids ahead of time, as Henry did, mention that you are taking a BPH medication and ask what your doctor advises.

Second, if you are at risk for acute urinary retention, it means your symptoms have progressed so that your urinary difficulties are moderate to severe in intensity (see “BPH progression,” above). It may be time to consider switching to a 5–alpha-reductase inhibitor. Because these medications reduce the size of the prostate and thus ease constriction of the urethra, they also reduce the risk of developing acute urinary retention and having to undergo surgery (see “Two additional benefits,” below).

Two additional benefits

A clinical trial involving more than 3,000 men, comparing finasteride (Proscar) with placebo, found that only 3% of men taking finasteride developed acute urinary retention (versus 7% taking placebo), and 5% eventually required surgery (versus 10% taking placebo).

Source: McConnell JD, Bruskewitz R, Walsh P, et al. The Effect of Finasteride on the Risk of Acute Urinary Retention and the Need for Surgical Treatment Among Men with Benign Prostatic Hyperplasia. New England Journal of Medicine 1998;338:557–63. PMID: 9475762.

Making a decision

Obviously the decision about whether to make some change in your medication regimen for BPH — whether it involves changing the dose or switching medications — is a complex one. You alone know how bad your urinary symptoms are, and what other health issues and trade-offs you need to consider.

Table 2 summarizes the salient information by drug and suggests the type of men who might want to consider taking one drug rather than another. Ultimately, of course, you are the authority when it comes to your own body, and different people metabolize drugs in different ways, so these general guidelines should be viewed as just that — general.

Even so, the information in this table, and in the rest of this article, may help you clearly evaluate your medication options. And if you ultimately decide that medications are not providing you with sufficient relief, it may be time to look into surgical options.

Table 2. General guidelines for BPH medications

Medication and mechanism of action Potential side effects You might want to consider using if You may not want to use if
Alpha-1 blockers (nonselective)

doxazosin (Cardura, generic)

terazosin (Hytrin, generic)

How they work

  • Relax smooth muscles in the urinary tract, allowing urine to flow more freely
  • Also affect other smooth muscles throughout the body
  • Dizziness, headache, and fatigue (most common)
  • Nasal congestion, dry mouth, and swelling in the ankles (occasional)
  • Retrograde ejaculation and other ejaculatory problems (occasional)
  • Hypotension (low blood pressure); may pose a danger for some men (rare)
  • You have a normal to moderately enlarged prostate (under 35 grams)
  • Cost is a consideration (these drugs are available in generic forms)
  • You want something with a proven track record that works within weeks
  • You have mild hypertension and want to reduce blood pressure while also treating BPH
  • You suffer frequent urinary tract infections
  • You have severe BPH
  • You have hypertension or heart disease (check with your doctor about mixing medications)
Alpha-1 blockers (selective)

alfuzosin (Uroxatral)

silodosin (Rapaflo)

tamsulosin (Flomax, generic)

How they work

  • Relax smooth muscles in the urinary tract, allowing urine to flow more freely
  • Act more selectively on muscles in the urinary tract than elsewhere
  • Dizziness, headache, and fatigue (most common)
  • Nasal congestion, dry mouth, and swelling in the ankles (occasional)
  • Retrograde ejaculation (may occur with tamsulosin; less likely with alfuzosin)
  • Erectile dysfunction (possible but less likely than with 5–alpha-reductase inhibitors)
  • You have a normal to moderately enlarged prostate (under 35 grams)
  • You are taking a medication for hypertension and want to use an alpha-1 blocker
  • You are concerned about diminished ejaculation (less likely with alfuzosin)
  • You suffer frequent urinary tract infections
  • You have severe BPH
5–alpha-reductase inhibitors

dutasteride (Avodart)

finasteride (Proscar, generic)

How they work

  • Reduce the size of the prostate, easing pressure on the urethra and allowing greater urine flow
  • Prevent the conversion of testosterone into dihydrotestosterone (DHT), which stimulates prostate growth
  • Decreased libido (occasional)
  • Decreased volume of ejaculate (occasional)
  • Erectile dysfunction (occasional)
  • Gynecomastia (rare)
  • You have a large prostate (more than 55 grams)
  • You want to avoid surgery (these drugs reduce the likelihood)
  • You are patient (the drugs may take at least six months to act, and up to two years to show full benefits)
  • You want to reduce your overall risk of prostate cancer (but see caveat, next column)
  • You are concerned about your risk for aggressive prostate cancer (finasteride may increase this risk)
  • Cost is a consideration (both drugs are expensive and not yet available as generics)

Originally published Jan. 1, 2007; last reviewed April 22, 2011.

Robert Antonik

I presently take both Tamsulosin and Finasteride and was wondering if I should quit taking the Finasteride because the increased risk of getting prostate cancer plus the cost of my
generic meds increased by 5.00 a month this year which isn’t a whole lot though. But my doc said that the chances of getting prostate cancer from taking finasteride are very minimal and I think it is shrinking my prostate. Although, I don’t notice any difference by taking it!


There are ample web resources that help understanding the probable causes and treatment of breast enhancement in males, which is commonly known as gynecomastia, so you can seek more information about the topic, and try finding out the best medical aid.


Thorough and easy to comprehend. Lots of information provided in a short, easy to digest format. Thank you.

Dick Plastino

This is a very good article and covers all the bases. I take both Flomax and Avodart (for only 6 months). The Avodart hasn’t made any difference so far, but apparently that is normal. I’ve been taking Flomax for about 10 years and recently have started having more problems than usual with light headedness and fatigue. I’m going to try the “every other day” Flomax regimen discussed in the article.


Great summary (I wish my urogists provided this info). Tha nk you!
How does the supplemental testosterone therapy relate to BPH treatment?
At ~65, over a year ago, I was put on supplemental testosterone (injection, 1ml/2weeks) to cope with fatigue due to lower T-levels (no sexual problems).
Now I developed (after an episode of prostatitis) a BPH (30-40mg), and I am contemplating a proper course of threapy. It seems that perhaps I should quit supplementary T (which may contribute to BPH). On the other hand, I know that lower T-levels (extending my 2-week period) result in unpleasant physical weakness.


I am a 64 year old man in good health (PSA .5) with the exception of some prostate issues. I am told that my prostate is not very enlarged. However, I have been on all of the typical medications mentioned here with nothing but detriment side effects. My problems: For about 2 years, the rate of my urination has reduced. This is not a significant because a few more seconds of urination does not adversely affect my life. However, having to wake to urinate once or twice a night has had a huge detrimental effect on life. Now my issue, there are lots of discussions, but none address my question. During a nightly urination, the volume of urine seems to be about half of a full bladder. If urine is collected for the entire night, it seems to be of a normal volume. With enlargement of the prostate, why has the volume of the bladder been cut in half requiring multiple urinations? The reason I usually read is that the prostate protrudes into the region of the base of the bladder. For the prostate to decrease the volume of the bladder by a half, it would have to be approximately half the size of the bladder and be in the perfect upward position which I never see in drawings or, push only the bladder opening (to the prostate) up approximately to half its height. I am wondering if the problem is actually coelomic adipose tissue in the region just protruding against the bladder wall instead of the prostate. Your comments please.


My PSA was on 2.2 and taking Avodart the dr. prescribe Cardura because of erectyle.disfunction and know after a year taking this medication my PSA is up to 3.1, could it be the cardura. Please help me because I dont see my urologist until the middle of October an I worry too much. Thank you.

Lou Bodnar

Excellent write-up, very informative. I am 60 and have been taking Cardura (4mg/daily) for approx. 5 yrs. for BPH, my PSA has risen from 4 to10 over this period of time, I have had 4 biopsies, all negative for cancer. However, around the time of my last biopsy, I had started experiencing pressure on my stomach and bladder, the biopsy was negative and I have since had an endoscope, which was normal and a colonoscopy which was fine. I am not getting any answers from my urologist. I feel like something abnormal is happening but i dont know what. Do you have any suggestions for my next step? Many Thanks .


Very informative article. I am 63 and taking both thamsolin and avadit for the last two years. How long one can have and when should I stop taking these.

R I Layard

Seems that nothing is ever told to patient about side effects or long term use of drugs. Very little information is given about dangers of surgical interventions. Thanks for good article. Most informative.

Walt Farnlacher

Very informative article. I wanted to know when to consider taking Proscar as recommended by my urologist. I do not have acute urinary retention yet. I am 69 and have been on Flomax for 10+ years. I increased from 0.4mg to 0.8mg but still get weak stream at times. Those times are; after sitting for 2 hours at a movie, after waking up during sleep once or twice at night. I mentioned that to my doc and he suggested taking proscar. I would think flomax would also be taken at the same time until the prostate shrinks. I am not sure at this time what size I have but recall the doc saying about the size of an apple. Not a good comparison IMHO…apples vary in size. I also have ED but my med plan only allows for Levitra and at full price. I have not found Levitra to work very well. Viagra has worked well in the past but not available to me. I am uncertain if proscar is right for me at this time.

harry edward

Thanks for your article.I need some help. My age is 83 Currently have 8MG of Terazoni at bed time. Get up 2 time every night. Have enlarge prostate. PSA reading is 12.5 to 13. Have readings done every year and the numbers remais about the same. Whay is your advise. Thanks. HE.

Donald L. Parsons

I have been taking 0.4mg of Tamsulosin every morning for over two years with good results except that I frequently could not sleep through the night with out urinating. About a year ago I experience a pulled muscle in my lower back from lifting a heavy object. To help with the discomfort I began taking two [2] 200 mg of ibuprofen each evening prior to going to bed.

I noticed that I was no longer having to go to the bathroom during the night. Is it possible that the ibuprofen help relax the smooth muscles in the prostate to alleviate the problem of nightly needing to urinate?

R E Reeves

A very well written, easily understood article – thank you. I am a 63 yr old male taking both Tamsulosin and Avodart for the past 2-3 years. This has helped my urinary symptoms considerably. A new insurance plan is no longer covering the Avodart so I am contemplating asking my urologist about switching to Finasteride which is a covered drug. This article has helped that decision process.

S. J. Goodman

Thanks very much for this article. My Urologist started me on Tamsulosin about a year ago. I had some side effects such as ED. He swithced me to Uroxatral which I have been taking for several months. Last week he had me start taking Cialis with the Uroxitral.
In you opinion is the combination safe and should I be taking them both at the same time?
Thank you for your help.

william curless

This is all great information but my question is:

I am 68 yrs old and have been taking Flomac and Finisteride daily, I would like to switch to more of an herbal remedy such as Zinc, Pommagranite juice, Saw Palmetto etc. for an enlarged prostate, although the Doc, after last exam, said it was at a normal size for my age
What would be the side effects to stopping the Flomac and Finisteride? My PSA is 12 and has been consistant for over a yr. I have been on Flomac and Finisteride for a year also.


Nice and highly educative article on BPH. I am 72 years old and on Tamsulosin .4 mg for the last five years. My flow of urine has reduced from 15 ml/sec to 7ml/sec and my PSA has increased from 1.7 ng to 2.08 ng in these five years Wt of prostate is 36gms. At times I have difficulty in passing the urine and I feel pain and tenderness in my Hypogastrium. My urine exam reports show 3-4 pus cells. Pl. advise how to overcome this problem and for how long I can take Tamsulosin safely.

Chris Herzog

I was given Tamsulosin 0.4mg by a Urologist because I have 2 kidney stones. He said that the Tamsulosin will relax the ureters and bladder to help the stones pass better.
I noticed on everything I have seen including the information sheet that comes with the prescription regarding side effects that one possible side effect is that you could get an erection that lasts longer than 4 hours. I have not seen this side effect mentioned in your article. This side effect worries me as I’m drinking a lot of water to flush the stones out and if I get this side effect I will not be able to urinate making my situation worse. Is the lengthy erection a possible side effect?

Also can I take Tamsulosin if I have a heart murmur?

Steven Tay

Many thanks for such an informative easy-to-read article. I am 63 and have been taking Avodart and Xatral for several years due to BPH. I was concerned about taking Viagra in combination with the BPH meds but after reading your article I am clear about the precautions to take.
Thank you again.

Brian Ferrara

Great article. I am 64 yo. After taking Avodart daily for several years I experienced ED. I got off the Avodart and erection returned. I now only take Avodart as needed, approx one pill every 10 days. When I have to urinate more than once a night it is time for a pill. This strategy was approved by my doctor. Your comments please.

Charles Verosini

200 mg of Ibuprofen at bedtime has eliminated my nightime
urination problem…I am 84 years old and take no prescription drugs although all those mentioned in the article have been prescribed. I choose not to deal with
side effects. Why don’t doctors tell male patients to try
this first??? It works for me and my urologist admits it
works for other patients of his?


In the column to the far right it states that “you may not want to use it” for the very reason it was prescribed?! Alpha- one blockers are prescribed for BPH so if you have frequent UTIs one shouldn’t take the meds? Or am I interpreting this all wrong?!

Cliff Lawson

At 87 and having never taken these drugs before and not having ED, I started on tamsulosin 10 days before a hernia repair operation. Reason is to offset the shock to the bladder because of the operation and it might otherwise shut down. Prior to this I regularly take zinc, magnesium and L-argenine. The L-argnine produces the nitric oxide that viagra would produce and much cheaper. Have had reduced urine flow and frequent night trips to bathroom. With 2 doses of the tamsulosin 0.4 mg, already the stream is like a fire hose. Doc says I may want to continue it after the operation. It appears that a half dose probably will be plenty.


Been taking Alfuzosin for the past 5 years… Starting to wonder if the extreme fatigue I am feeling is from this med???… stuffy nose and a very dry mouth …

Richard Ledford

Just over two years ago, my gradually but steadily worsening BPH symptoms suddenly spiked to the point where I ended up in the hospital with acute urinary retention. This led to being on a full time indwelling catheter while I started taking tamsulosin to if it could improve my condition enough to atop needing a catheter and start planning for green laser (or other) surgery.
The medication ended up giving effectivly ZERO relief, and it was clear that I needed the laser procedure sooner rather than later. Being an uninsured self pay patient at the time, I struggled to be financially able to afford the cost of this treatment plan.
I quickly adapt to having an indwelling catheter, and I learned how to become a “self cath” patient, replacing my catheter every 4-8 weeks.
Over these now two plus yers, I always tried to go as long as possible between old catheter removals and swapping in a new one. After removal I could typically have some poor degree of bladder control and flow, but within 24-48 hours I would revert to the acute retention status.
My observations of what happens with the progression of BPH to the severe level over time, and what doctors never clearly explain, is that as the prostate steadily pinches tighter around the urethra, the minimum level of bladder PRESSURE needed to initiate flow gets steadily higher, and the bladder muscles start having difficulty producing this level of flow starting pressure by themselves.
The result is that the bladder gets stretched further, and this extra stretching raises the PRESSURE inside the bladder to the level where the combination of BOTH the bladder muscles AND the stretching induced extra pressure, together allow for reaching a high enough pressure level to overcome urethra pinching and initiate flow.
However, when flow does finally start, is only at enough pressure establish weak flow, and after only a fairly small per cent of the bladder’s total urine “inflation” has emptied, the subsequent reduction of pressure from the loss of bladder stretch drops it below the point where flow can be maintained, choking it down to a sporadic dribble level.
How, as a result of the bladder’s PARTIAL urine evacuation lowering pressure in the bladder, the previously backed up kidneys jump for joy and immediately resume sending some of their excess urine accumulation down into the bladder, causing pressure there to rise again, and to reach the point where flow from the kidneys drops off. This fresh and rapid rise in bladder pressure from backed up kidneys’ unloading into a NON-EMPTIED bladder, is what gives the urge to pee again so soon after just having peed, and the boost of bladder pressure is just enough to trigger the urgent need for another PARTIAL voiding of the bladder to needed, often just a few minutes after the prior urination ended. This vicious cycle of weak and partial urination only gets worse with time unless treated.
This summarizes my view of what happens at the more severe stages of the BPH condition.
It certainly is no good for the kidneys to keep having to “inflate” the balloon size of the bladder to higher and higher pressure levels, in order to sufficiently assist the bladder muscles to reach the high enough levels of EXCESS PRESSURE needed to allow some limited amount of urine flow starting to pass through a thoroughly pinched urethra, but only lasting long enough to give a partial bladder evacuation. -RRLedford

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